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'A CALORIE IS A CALORIE' IS AN AMBIGUOUS PHRASE.
IN ONE SENSE IT IS TRIVIALLY TRUE, AS IN GERTRUDE
STEIN'S FAMOUS PHRASE, 'A ROSE IS A ROSE IS A ROSE
IS A ROSE'. In another sense it is obviously questionable,
because it assumes no difference between the energy
produced by burning food in a bomb calorimeter and that
generated by metabolic processes. It also assumes that as far
as effect on body weight is concerned, fat is bad because fat by
itself is calorie-dense per unit of weight, and carbohydrate and
protein are good because they are relatively low in calories. It
further assumes that in terms of weight gained or lost, there
is no difference between diets that include the same number
of kilocalories say from rice, greens and fish, or from French
fries, burgers and cola, or from Danish pastries, frappuccinos
and gin slings.1

Over the last decade, researchers have started looking
more closely at assumptions going back more than a century
regarding calories and the macronutrients carbohydrate, fat
and protein. Most dieters are familiar with calorie counting
and long lists of calorie tables for food portions. Indeed, the
FDA mandates this information on Nutrition Facts panels
and even some dietary supplements have begun to engage
in this practice. One problem, as most dieters learn from
bitter experience, is that over the long term calorie counting
does not work. Other than in starvation mode, a condition
under which all calories consumed regardless of their source
are metabolized quickly to fill the deficit, the body treats
calories from different sources differently and it treats calories
according to the combinations in which they are consumed,
the time of day, and so forth and so on. Food preparation,
meal preparation, dietary patterns, etc., all count. In other
words, it is not true that a calorie is a calorie is a calorie.

Eat Fat, Live Longer?
Let's start with an extreme, the effect of a ketogenic diet. In
this diet, the preponderance of calories is derived from fats.
A University of California, Davis study published early this
year, found that a long-term ketogenic diet (89–90 percent of
total calorie intake) in a mouse model significantly increased
median lifespan and survival compared to controls. Moreover,
in aged mice only those consuming a ketogenic diet preserved
normal physiological functions (strength, coordination,
prevention of age-related markers of inflammation). In short,
the ketogenic diet, even though it did not alter the maximal
span of life, extended both overall longevity and healthspan in
mice.2 How much? There was a 13 percent increase in median
life span for the mice on a high-fat versus high-carb diet. In
humans, that would be seven to 10 additional years with better
health along the way.

Another research team, this time at the University of
California, San Francisco and associated aging institutes,
discovered that a cyclic ketogenic diet, meaning that it was
alternated weekly with the control diet to prevent obesity,
reduced midlife mortality without affecting maximum lifespan.
The researchers observed that a non-ketogenic high-fat diet
fed similarly may have an intermediate effect on mortality. A
non-obesogenic ketogenic diet improved survival, memory,
and healthspan in aging mice according to these finding.3

Note that there was no attempt in the foregoing studies to
determine whether a change in the nature of the carbohydrates
fed to the animals in a non-ketogenic high fat diet affects
outcomes. However, even without a direct study, evidence
abounds from indirect studies. Many carbohydrate sources
are close to fiber in their influence on blood sugar levels and,
in line with this, promote digestive health and gut probiotic
diversity. In contrast, the modern American and common
Western diets in general are ultra-processed diets. The
healthfulness of ultra-processed foodstuffs is quite different
from that of foods processed and prepared more traditionally,
including, it turns out, from supposedly unhealthful foods.

Ultra-processed Foods
A few years ago, Harry Preuss, MD of Georgetown University
and I wrote a chapter for a medical text on the metabolic
syndrome. We began by observing.

Throughout the world, many elements comprising
the Metabolic Syndrome (MS) such as diabetes, obesity,
hypertension, and dyslipidemias are becoming alarmingly
common. Although many etiological factors may be involved
in this situation, one hypothesis is that a well recognized
increased consumption of sugars and refined carbohydrates
(CHO) such as sucrose and high fructose corn syrup (HFCS)
plays a pivotal role in the increase of these unwanted entities.4

An Increasing Content of Empty Calories
Food refining, processing and meal preparation techniques
favored in the United States and in much of the Western World,
including especially fast and convenience foods, have led to dramatic changes in food quality. Definitions of ultra-processed
foods provide clues as to why this should be the
case. In one study of dietary intakes of 9,317 participants from
2009 to 2010, food items were classified into unprocessed or
minimally processed foods, processed culinary ingredients,
processed foods, and ultra-processed foods.5

Ultra-processed foods are formulations manufactured
using several ingredients and a series of processes (hence
"ultra-processed"). Most of their ingredients are lower cost
industrial sources of dietary energy and nutrients, and
additives used for the purpose of imitating sensorial qualities
of minimally processed foods or of culinary preparations of
these foods, or to disguise undesirable sensory qualities of
the final product. They are made to be hyper-palatable and
attractive by the use of many additives, with long shelf life, and
are able to be consumed anywhere, anytime. Ultra-processed
foods include but are not limited to soft drinks, sweet or
savory snacks, reconstituted meat products, and pre-prepared
frozen dishes.

The average content of protein, fiber, vitamins A, C, D, and
E, zinc, potassium, phosphorus, magnesium, and calcium
in the US diet are decreased significantly in ultra-processed
foods, whereas carbohydrate, added sugar, and saturated fat
contents are increased. As the degree of ultra-processed food
increases as the source of total calories, the overall dietary
quality measured in terms of a nutrient-balance-pattern of
fiber, potassium, magnesium and vitamin C goes down.

In another study, "ultra-processed foods were defined as
industrial formulations which, besides salt, sugar, oils and
fats, include substances not used in culinary preparations,
in particular additives used to imitate sensorial qualities of
minimally processed foods and their culinary preparations."
In the 2009–2010 National Health and Nutrition Examination
Survey of the US diet, ultra-processed foods were found to
constitute 57.9 percent of total energy. The content of added
sugars in ultra-processed foods (21.1 percent of calories)
was eight times that in processed foods (2.4 percent) and
five times that in unprocessed or minimally processed foods
and processed culinary ingredients grouped together (3.7
percent). Consumption of added sugars increased linearly as
ultra-processed food consumption increased. It went from
7.5 percent of total energy in those in the bottom one fifth of
consumption of ultra-processed foods to 19.5 percent in the
highest one fifth. A total of 82.1 percent of Americans in the
highest quintile exceeded the recommended limit of 10 percent
energy from added sugars compared with 26.4 percent in the
lowest.6

Consequences of Differences in Food Quality
As populations shift from more traditional foods and food
preparations, there can be serious consequences. These
consequences include increases in obesity and cardiovascular
disease. As an example of the first of these, a study of food
consumption in nineteen European countries spanning
1991—2008 found a clear pattern. There was a median
average household availability of 33.9 percent total purchased
dietary energy for unprocessed or minimally processed foods,
20.3 percent for processed culinary ingredients, 19.6 percent
for processed foods and 26.4 percent for ultra-processed
foods. The average household availability of ultra-processed
foods ranged from 10.2 percent in Portugal and 13.4 percent
in Italy to 46.2 percent in Germany and 50.4 percent in the
UK. As the percentage of total energy from ultra-processed
foods increased, so did the rate of obesity. On average, for
each percentage point increase in the household availability
of ultra-processed foods there was an increase of 0.25
percentage points in obesity.7 Estimates suggest that merely
cutting in half the amounts of processed and ultra-processed
foods consumed as components of the overall diet in the UK
could result in approximately 13 percent fewer deaths from
cardiovascular diseases by 2030.8

Benefits of Traditional Foodstuffs
Ultra-processing is but one issue among several regarding
the impact of modern farming, processing and preparation of
foods. It does not take into account the benefits of returning
to farming practices less dependent on chemical fertilizers,
pesticides and fungicides or intensive energy use. It does not
take into account the effects of removing genetically modified
organisms from the food chain. It does not take into account
returning to the use of varietals that produce more protein
and minerals per acre and less starch, and so forth and so
on.9 Nor does it take into account issues such as the negative
consequences of the consumption of ultra-pasteurized and
homogenized milk nor the move to A1 milk (the A1 protein
is actually a histidine-rich mutated form of casein, and is
commonly found in US dairy products).10

Going Organic and Non-GMO
Can such changes be embraced? Much evidence suggests that
the answer is "yes" to all points. This includes lower use of
pesticides, higher yields in nutrients and experimentally better
results from consuming the resulting foodstuffs.11,12,13,14,15,16 A
significant finding from a 30-year ongoing trial is that organic
farming is not less efficient nor inferior in production for many
or even most crops. After a 30-year side-by-side trial, a report
by the Rodale Institute found:17,18

Organic yields match conventional yields.

Organic outperforms conventional in years of drought.

Organic farming systems build rather than deplete soil organic matter, making it a more sustainable system.

Organic farming uses 45 percent less energy and is more efficient.

Conventional systems produce 40 percent more greenhouse gases.

Organic farming systems are more profitable than conventional.

Unexpected Benefits of Traditional Foods

In previous Total Health articles, it has been pointed out that
a number of "exotic" foods, such as pomegranate, support
health in unexpected ways, such as promoting changes in
gastrointestinal bacteria. Now, it seems, that food items
traditionally found in European cuisines may have similar
benefits. For instance, the bacterium Propionibacterium
freudenreichii, which is used in the fermentation of
Emmentale—the proper name of Swiss cheese, because it
came from the Emmental region of Switzerland—benefits
health. The bacterium turns lactate into acetate, carbon dioxide
and propionate. Acetate and propionate are known to benefit
the immune system and propionate supports the health of
the lining of the intestinal tract. Other lactic bacteria in Swiss
cheese, Weisella koreensis and Weissella cibaria, extend the
lifespan by protecting the body against stress and the invasion
of pathogens and promoting an anti-inflammatory effect on
the immune system.19 Other aged cheese, such as cheddar,
blue, brie, Parmesan, Gouda, Gruyère and some forms of
mozzarella, also provide longevity and related benefits in a
number of models.

Another route by which gut bacteria improve health is
the production of a compound known as indole. Indole is
produced by many types of bacteria through breakdown of
the amino acid tryptophan.20 Indole and its chemical relatives
can be found in plants, especially vegetables such as broccoli
and kale. However, tryptophan also is found in eggs, cheese,
tofu, salmon, turkey and some nuts and seeds. The key for
transformation of the amino acid to indole is the gut bacteria,
hence success involves more than merely adding this amino
acid to the diet. Likewise, balance is the key: many meats supply
tryptophan and thus are healthful in appropriate amounts, yet
unbalance gut bacteria if consumed in excess.

Putting It Together
In August 2017, a major British cardiologist, Anseem
Malhotra, who holds that cardiovascular disease is caused
by inflammation rather than by fats,21 put out an interview
entitled, "Choose The Pioppi Diet Over Statins To Beat Heart
Disease."22 It provides an interesting discussion matching
much of the information found above. Here are some of the
key recommendations:

Don't fear fat. Sugar and refined carbohydrates are the real enemies.

Keep moving. Walk as much as possible.

Extra virgin olive oil is medicine. Eat some every day. And nuts are important, too. Pioppians eat plenty of hazelnuts, walnuts, and almonds.

Get seven hours of sleep a night. Adequate sleep is required for good health.

Stop counting calories. What you eat is more important than how much you eat.

Eat eggs. Many Pioppians eat 10 a week.

Pile on the vegetables. Eat big helpings of fresh, organic vegetables in at least two meals a day.

Long time readers of TotalHealth will recognize that Dr.
Malhotra's recommendations based on his study of Pioppi
longevity look quite similar to the Okinawan dietary pattern
in many respects. Along with an only moderate intake of
carbohydrates (much less rice than is typical of the Japanese
diet generally) and plenty of fish and eggs, the Okinawans
consume bitter melon similarly to how the Pioppians consume
extra virgin olive oil, which is to say, routinely or even daily.
The evidence is that these types of dietary practices coupled
with exercise and other healthful habits reduce most of the
elements that we have come to associate—wrongly—with
declining health in advancing years.23

Dallas Clouatre, PhD

Dallas Clouatre, Ph.D. earned his A.B. from Stanford and his Ph.D. from the University of California at Berkeley. A Fellow of the American College of Nutrition, he is a prominent industry consultant in the US, Europe, and Asia, and is a sought-after speaker and spokesperson. He is the author of numerous books. Recent publications include "Tocotrienols in Vitamin E: Hype or Science?" and "Vitamin E – Natural vs. Synthetic" in Tocotrienols: Vitamin E Beyond Tocopherols (2008), "Grape Seed Extract" in the Encyclopedia Of Dietary Supplements (2005), "Kava Kava: Examining New Reports of Toxicity" in Toxicology Letters (2004) and Anti-Fat Nutrients (4th edition).

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